Emerging Technologies and New Technological Concepts

Four-Corner Concept: CT-Based Assessment of

Fracture Patterns in Distal Radius
P. R. G. Brink, MD, PhD1 D. A. Rikli, MD2

1 Department of Traumatology, Maastricht University Medical Center, Address for correspondence P. R. G. Brink, MD, PhD, Department of
Maastricht, The Netherlands Traumatology, Maastricht University Medical Center, P. Debyelaan 25,
2 Department of Traumatology, Universitätsspital Basel, Basel, 6202AZ Maastricht, The Netherlands (e-mail: p.brink@mumc.nl).
Switzerland

J Wrist Surg

Abstract Operative treatment using plate fixation is an important adjunct in the treatment of
distal radius fractures, although the evidence for its superiority over other modalities
remains limited. We propose a new concept for fractures of the distal radius, based on
the three-column model of the distal radius, and on the expanding knowledge about the
different fracture patterns obtained by evaluation of the distal radius by computed

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Keywords tomographic (CT) scan. All fracture types can be characterized by subdividing the wrist
► distal radius fractures joint into four corners, each with its own characteristics in terms of mobility, stability,
► intra-articular and transfer of forces in the intact distal radius. Recognition of the specific fracture
fractures types based on this four-corner concept enables a tailored approach to treatment.

Four-Corner Concept
The four-corner concept is based on the combination of the
three-column model of Rikli and Regazzoni 1 and Melone’s
four-part classification.2 The radius-ulna complex can be
divided into four corners, each of which has a special
biomechanical function and its own behavior after injury
(►Fig. 1). At least eight different fracture patterns can be
distinguished, with and without a fracture of the ulna
(►Fig. 2). In extra-articular fracture patterns, the radial,
dorsal, and ulnar corners remain as an intact block, which is
separated from the shaft, ulnar corner, or both. In partial
intra-articular fractures, theoretically six different pat-
terns can be described depending on which corner is
fractured. Per definition, at least one corner remains intact
and in continuity with the shaft. The radial, dorsal, or volar
corner can be involved individually or in paired combina-
tions: radial and dorsal, radial and volar, and dorsal and
volar. In complete articular fractures, all articular compo-
nents, that is, the radial, dorsal, and volar corner are
separated from the shaft.
The radial corner is responsible for radiocarpal stability
and is formed by the radial styloid and scaphoid fossa to
which the strong volar radiocarpal ligaments are attached. In
fracture dislocations, the styloid can be torn off (as an
equivalent to a tear of the radiocarpal ligaments: a bony
avulsion) and is displaced distally and ulnarly (avulsion type).
If predominantly compression and bending forces are
involved (compression type), the fragment tends to rotate
into supination and displace proximally due to the attached
insertion of the brachioradial muscle. Usually an intra-artic-
ular step-off is present.
The ulnar corner consists of either the ulnar head or ulnar
styloid, and is important for distal radioulnar joint (DRUJ)
stability. It is the stable pivot around which the radius rotates.
Ulnar styloid fractures can be left untreated when the DRUJ is
stable3,4 but must be addressed in case of instability due to a
disruption of the deep radioulnar ligament attachment.
Additionally, the ulnar corner plays an important role in force
transmission across the wrist joint. In vivo measurements
have shown that up to 50% of forces are transmitted across the
ulnar column with physiologic unloaded motion.5
The intermediate column that takes a large part (> 50%) of
the axial compressive forces that are transmitted across the
wrist during normal activity5 consists of the lunate fossa and
the sigmoid notch. In the fracture setting, an axial CT scan is

received Copyright © by Thieme Medical DOI http://dx.doi.org/

August 19, 2015 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1570462.
accepted after revision New York, NY 10001, USA. ISSN 2163-3916.
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CT-Based Assessment of Fracture Patterns in Distal Radius
Fig. 1 An axial CT view allows four corners of the distal radius and ulna
to be distinguished. The volar and dorsal corner fragments are those
involving the sigmoid notch.
Fig. 2 A total of eight different fracture patterns of the distal radius
can be distinguished. Besides extra-articular (A) and complete intra-
articular fracture patterns (C), theoretically six different partial intra-
articular patterns (B) are possible, but some will be extreme rare in
clinical practice.
the best method to visualize whether there is a sagittal split of
the lunate fossa into a dorsal and a volar fragment (corner).
An isolated fracture of the dorsal corner is seldom seen. It
usually occurs in combination with a radial corner fracture
and/or volar corner fracture. As part of the dorsal corner,
Journal of Wrist Surgery
Brink, Rikli
small central articular fragments that are impacted into the
metaphysis can be seen here and can only be reduced through
a dorsal approach. If the dorsal corner fragment is substantial
and displaced, it should be addressed specifically. A mal-
united dorsal corner fragment affects the congruency of the
radiocarpal joint surface and of the sigmoid notch (DRUJ), and
can be disastrous if not treated properly (►Fig. 3).
The volar corner, in case of a complete articular fracture,
tends to rotate dorsally (extension) due to the pull of the volar
radiocarpal ligaments. The volar corner has the thickest
cortical bone and comminution is therefore seldom seen,
but if the buttress of this fragment is lost due to cortical
comminution, direct reduction and fixation are necessary. If
shear fragments of the volar corner are present (“reverse
Barton”), small “volar rim” fragments of the carpus tend to
sublux volarly due to the strong radiocarpal ligaments.6,7
Great care must be taken to firmly fix this fragment, especially
when this fragment is small, to avoid secondary displacement
with subluxation of the proximal carpal row (►Fig. 4). Mal-
rotation of the volar and dorsal corner in the sagittal plane
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with clockwise rotation of the dorsal corner fragment and
counter-clockwise rotation of the volar corner fragment can
result in narrowing of the radiocarpal joint surface with
clinically relevant loss of wrist flexion/extension.8,9 The three
corners of the radius actually correspond with the osseoliga-
mentous units, described by Bain et al.10 Based on studies in
the past, fragments tend to be fixed to the ligaments, whereas
the fracture lines are basically in the so-called interligamen-
tous zones.10 This might explain the recurrence of the specific
fracture configuration.
The “Key Corner”
The four-corner concept draws attention to a clinical obser-
vation coined “the key corner”: the sagittal reconstruction of
the CT scan is analyzed at the level of the intermediate
column; in some situations it can be demonstrated that the
lunate (the proximal carpal row) goes together with a dis-
placed either dorsal or volar corner fragment into slight
subluxation. This carpal subluxation is probably more impor-
tant than a step-off (without subluxation) and should be
corrected to avoid chronic subluxation with alteration of the
entire joint kinematics. The fragment with which the lunate
goes is considered the “key corner” and its control with
reduction and stable fixation should be the first step and
an integral part of the operative strategy. This fragment is not
necessarily the largest fragment on the CT scan (►Fig. 5).
Fracture Patterns
Extra-articular fractures of the distal radius can affect the
DRUJ (ulnar corner in relation to the intermediate column) or
the radiocarpal and midcarpal joints in case of dorsal or
volar tilt.
The best way to regain full function is to restore the
anatomy between the radius and ulna.11 In (partial) intra-
articular fractures the CT scan helps us assess the size and
relevance of the specific corners. Small fragments could
 CT-Based Assessment of Fracture Patterns in Distal Radius Brink, Rikli

Fig. 4 In this case the volar ulnar corner was not captured with the
volar T-plate, resulting in secondary displacement.

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Fig. 3 Although the distal fragments were fixed with a volar plate with
seven screws, the dorsal corner was not fixed, leading to an intra-
articular malunion with malalignment of the DRUJ joint.
indicate radiocarpal instability, due to ligamentous avulsion,
and are per definition unstable. Any displaced volar or dorsal
corner in respect of the other corners and/or shaft, which is
still related to the lunate bone, needs attention. When the
proximal row follows the dislocated fragment of the radius
resulting in a subluxation, this fragment (the key corner)
should be addressed, either from the volar or the dorsal side,
and needs to be reduced and fixed. It is hardly possible to
reduce a dorsal key corner from the volar side and in those
cases a dorsal approach is advised. A straight approach
between the third and fourth extensor compartment and
fixation with a fragment-specific plate under the envelope of
the extensors digitorum (fourth compartment) is advocated
(►Fig. 6). When both corners are separated, leaving the
lunate in between (►Fig. 5d), there is no key corner, but
reduction and fixation of both is mandatory to restore intra-
articular anatomy (sandwich or triple plating) (►Fig. 7).
Recognition of the correct fracture pattern is the most
important first step to identify which corners are involved
and which corner needs reduction and fixation. Classification,
using CT scans are more reliable than plain X-rays.12 In
general all helical CT scans with routine axial and sagittal
and coronal reformatted images views with 2-mm-thick
images at l- or 2-mm intervals will do. Displacement between

Fig. 5 Although there is a large variety in the size of the volar and dorsal corner, the fragment that is in congruency of the lunate is the key
corner. ►Fig. 5d shows a separate volar and dorsal corner, both in contact with the lunate bone. No key corner can be distinguished.

Journal of Wrist Surgery

CT-Based Assessment of Fracture Patterns in Distal Radius
Fig. 6 Intra-articular fracture in which the lunate is in line with the
dorsal corner (key corner) and subluxated from the volar corner.
Therefore, a dorsal approach and fixation are preferred.
the corners can be seen on the axial view, but displacement
between the corner and the radial shaft and the carpal
subluxation can only be judged on the reformatted views.
The axial view shows the relation between the volar/dorsal
corner and its relation with the ulnar corner. If the volar corner is
not displaced in relation to the ulna (►Fig. 7a), the shaft of the
radius needs to be realigned with this fragment first and
afterward the dorsal corner should be reduced in the direction
of the volar corner. If the volar corner is displaced in relation to
Fig. 7 Intra-articular fracture in which both corners are involved. No
key corner could be identified, but both fragments are substantial,
indicated by sandwich plating.
Journal of Wrist Surgery
Brink, Rikli
Fig. 8 Classic shear-type fracture. The lunate stays in contact with the
volar corner (key corner). Volar approach with reduction and plate
fixation of the volar corner restores alignment of the carpus in relation
to the radial shaft.
the ulnar corner, this fragment should be reduced (by a volar
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peri-FCR approach). In the sagittal view a volar subluxation of
the lunate is part of the fracture configuration (►Fig. 8).
The presence of metaphyseal comminution (especially on
the volar side) is a sign of instability, which needs to be
addressed and needs proper reduction and adequate fixation
and is an independent factor concerning treatment strategy.
In most cases the use of longer plates makes it possible to
bridge the metaphyseal area and regain enough stability for
functional after treatment.
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Journal of Wrist Surgery